INITIAL COMMENTS
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This report is a result of an onsite licensure renewal inspection. The inspection was conducted on December 6, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Nuestra Clinical of SACA was found to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill record log, the facility failed to document three monthly fire drills.
The findings include:
The fire drill record log was reviewed on December 6, 2012. The log was reviewed from November 2011 to November 2012. Three of those months did not document that a fire drill was conducted. December 2011, May 2012 and November 2012 failed to have monthly fire drills conducted.
This was confirmed with the associate director on December 6, 2012.
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Plan of Correction
The facility is combined with another agency, so a meeting was held between directors and it will be the program director's responsibility to ensure drills are completed monthly on a rotating schedule using different exit points throughout the building. The program director will assume responsibility for scheduling and reviewing the fire drills on a monthly basis. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the fire drill record, the facility failed to ensure that fire drills were conducted during different times of the day.
The findings include:
The fire drill record was reviewed on December 10, 2012. Twelve months of fire drills were reviewed. The facility's hours of operation are from 9:00 a.m. until 5:00 p.m. The facility failed to document fire drills between the hours of 9:00 a.m.- 2:15 p.m. All the drills were documented between 2:15 p.m. and 4:05 p.m.
This finding was discussed with the associate director and was not disputed.
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Plan of Correction
It is the responsiblity of the program director to ensure drills are completed rotating tinme schedule to ensure responses at different times of the buisness day. The program director will schedule drills for the entire year on a rotating time schedule and review fire alarms monthly to ensure compliance. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document the lengths and patterns related to the client's progression of drug and alcohol use in three of four records reviewed.
The findings were:
Four patient records were reviewed on December 6, 2012. All records required documentation of a drug and alcohol history that included lengths and patterns related to the client's progression of use. The facility failed to document the lengths and patterns related to the client's progression of use in patient records # 1, 3, and 4.
This finding was discussed with the associate director and was not disputed.
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Plan of Correction
The clinical supervisor met with the clinical staff and will be responsible for weekly random chart audits to ensure complete documentation of the progression of use. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in four of four client records.
The findings include:
Four client records were reviewed on December 6, 2012. Four client records contained individual treatment and rehabilitation plans which are required to include the type and frequency of treatment and rehabilitation services. The individual treatment and rehabilitation plans documented in records # 1, 2, 3 and 4 did not include the type and frequency of treatment and rehabilitation services.
Client #1 was admitted to treatment on September 12, 2012. The individual treatment and rehabilitation plan was developed on September 20, 2012. The therapist failed to document type and frequency of services required on the treatment plan.
Client #2 was admitted to treatment on August 9, 2012. The individual treatment and rehabilitation plan was developed on September 5, 2012. The therapist failed to document type and frequency of services required on the treatment plan.
Client #3 was admitted to treatment on August 8, 2012. The individual treatment and rehabilitation plan was developed on August 17, 2012. The therapist failed to document type and frequency of services required on the treatment plan.
Client #4 was admitted to treatment on September 17, 2012. The individual treatment and rehabilitation plan was developed on September 26, 2012. The therapist failed to document type and frequency of services required on the treatment plan.
This finding was confirmed by the associate director and was not disputed.
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Plan of Correction
The program director updated the format of the treatment plans to prompt documentation. The clinical supervisor discussed the implemented change and will be reponsbile for weekly chart audite to ensure compliance. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document support services on two of four client records reviewed.
The findings include:
Four client records were reviewed on December 6, 2012. Four client records were reviewed for documentation of proposed support services on the client's treatment plan. Client records # 1 and 2 failed to document proposed support services on the comprehensive treatment plan.
This finding was discussed with the associate director and was not disputed.
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Plan of Correction
The clinical supervisor will complete weekly chart auidts to ensure that support services are documented in the treatment plan as well as individualized notes. The staff had an in house training with progrram director on December 10, 2012 and will attend in house trainings quarterly to reinforce the need of continuity of care as well as the documentation of such care. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of client records, the facility failed to document in the treatment plan update the client's progress as it relates to the goals identified in the individualized treatment and rehabilitation plan in two of two records reviewed.
The findings were:
Four client records were reviewed December 6, 2012. It was determined that the therapist failed to document in the treatment plan update the client's progress as it relates to the the goals identified in the individualized treatment and rehabilitation plan for client records # 3 and 4.
Client # 3 was admitted on August 8, 2012. The comprehensive treatment and rehabilitation plan was documented on August 17, 2012. The treatment rehabilitation plan update was completed on October 19, 2012. The therapist failed to document the client's progress as it related to the goals identified on the individualized treatment and rehabilitation plan update.
Client # 4 was admitted on September 17, 2012. The comprehensive treatment and rehabilitation plan was documented on September 26, 2012. The treatment rehabilitation plan update was completed on November 21, 2012. The therapist failed to document the client's progress as it related to the goals identified on the individualized treatment and rehabilitation plan update.
This finding was confirmed by the associate director and was not disputed.
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Plan of Correction
The program director updated the format of the treatment plans to prompt documentation. The clinical supervisor discussed the implemented change with the clinicians and will be reponsbile for weekly chart audite to ensure compliance. there is a section noted for updates and goal attainment which was discussed with clinicians. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, there was no way to determine if the services being provided were according to the treatment and rehabilitation plan.
The findings include:
Four client records were reviewed on December 6, 2012. There was no documentation of how often the client should be engaging in treatment on the client's individual treatment and rehabilitation plan. There was no way to determine if services were being provided according to the plan.
This finding was confirmed by the associate director.
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Plan of Correction
The program director updated the format of the treatment plans to prompt documentation of any changes to treatment plan and how this change did or did not affect the overall goals and objectives. Therapist will document the type and frequency of treatment on the treatment plan and will ensure that the client's are attending treatment as prescribed. Attendance r lack of attendance will be documented on the record of service. The clinical supervisor will be reponsbile for weekly chart audits to ensure compliance. |
709.93(a) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
Based on the review of client records, the facility failed to document a complete record in three of three records reviewed.
The findings include:
Four client records were reviewed on December 6, 2012. Three of the four records were of bi-lingual clients and were required to have documentation in the client record both in English and in Spanish. Client records # 1, 2, and 3 had Spanish documentation of the client's orientation to treatment, consent to treatment, client rights and follow up letters in the client record. There were no English translation of the forms in the client record.
The facility associate director did sit with the licensing inspector to help translate the forms and confirmed this finding.
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Plan of Correction
The associate director will be respnsible for biweekly chart reviews to ensure the consent forms are complete. In addition the forms were changed to two sided documents which offer client information in both English and Spanish to ensure translation for both languages. The associate director met with staff and explained the process on december 10, 2012 and deveolped a master chart with the new forms removing all old forms from the chart and all clinicians. |